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The Role of Endoscopy in Gastroduodenal Obstruction and Gastroparesis

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The Role of Endoscopy in Gastroduodenal Obstruction and Gastroparesis GUIDELINE The role of endoscopy in gastroduodenal obstruction and gastroparesis This is one of a series of statements discussing the use of This document describes the role of endoscopy in known GI endoscopy in common clinical situations. The Stan- and suspected obstruction of the proximal GI tract. A dards of Practice Committee of the American Society for discussion of special considerations in a pediatric popu- Gastrointestinal Endoscopy (ASGE) prepared this text. In lation is also included. preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified ETIOLOGY AND PRESENTATION articles and from recommendations of expert consultants. Gastric outlet obstruction (GOO) is caused by mechan- Guidelines for appropriate use of endoscopy are based on ical gastroduodenal obstruction or motility disorders and a critical review of the available data and expert consen- can be divided into 3 major categories: benign mechanical, sus at the time the guidelines are drafted. Further con- malignant mechanical, and motility disorders (Table 2). trolled clinical studies may be needed to clarify aspects of Peptic ulcer disease with or without secondary stricture is this guideline. This guideline may be revised as necessary the most common cause of benign mechanical GOO, to account for changes in technology, new data, or other although the recent decline in peptic ulcer disease has aspects of clinical practice. The recommendations are decreased the incidence of clinically evident peptic stric- based on reviewed studies and are graded on the strength tures.2 Malignant mechanical GOO usually results from of the supporting evidence (Table 1).1 The strength of cancer affecting the distal stomach or proximal duode- individual recommendations is based both on the ag- num. Gastric and pancreatic cancers are the most common gregate evidence quality and an assessment of the an- malignant mechanical causes of GOO.3 ticipated benefits and harms. Weaker recommendations The most common gastric motility disorder is gastro- are indicated by phrases such as “We suggest ...,” paresis, often resulting from long-standing diabetes, al- whereas stronger recommendations are typically stated though gastroparesis may also be idiopathic, viral, or as “We recommended ...” related to medications.4-6 Surgical procedures that inten- This guideline is intended to be an educational device tionally or unintentionally disrupt the vagus nerve (eg, to provide information that may assist endoscopists in procedures for peptic ulcer disease, bariatric procedures, providing care to patients. This guideline is not a rule and esophagectomy, fundoplication) may also result in gastro- should not be construed as establishing a legal standard of paresis. Several solid and hematologic malignancies may care or as encouraging, advocating, requiring, or discour- induce gastroparesis and small-bowel dysmotility through aging any particular treatment. Clinical decisions in any a paraneoplastic process or secondary infiltrative diseases particular case involve a complex analysis of the patient’s (eg, amyloidosis, carcinomatosis).7,8 condition and available courses of action. Therefore, clin- Patients with GOO may present with nausea and vom- ical considerations may lead an endoscopist to take a iting, weight loss, abdominal bloating, early satiety, and/or course of action that varies from these guidelines. abdominal discomfort. Because of shared clinical features, Enteral obstruction and delayed gastric emptying can it is often difficult to distinguish motility disorders from result from a variety of benign and malignant conditions. mechanical obstruction or functional dyspepsia based 9,10 Endoscopy is an important tool in the evaluation of these solely on symptoms. Nevertheless, initial evaluation patients and can identify, localize, or exclude structural should include a detailed history and careful physical causes. Moreover, various endoscopic procedures may be examination. Vomiting soon after a meal suggests an up- used to treat the underlying etiology or alleviate symptoms. per anatomic abnormality, whereas symptoms delayed for several hours after meals characterize gastroparesis or a more distal obstruction.11 Vomiting will frequently relieve symptoms from a proximal obstructive cause. GOO may not be clinically evident until high-grade obstruction occurs be- cause of the ability of the stomach to distend significantly to Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 accommodate contents. Patients with GOO may demonstrate doi:10.1016/j.gie.2010.12.003 a succussion splash on physical examination. www.giejournal.org Volume 74, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY 13 The role of endoscopy in gastroduodenal obstruction and gastroparesis Table 1. GRADE System for rating the quality of evidence for guidelines Quality of evidence Definition Symbol High quality Further research is very unlikely to change our confidence in the estimate of effect QQQQ Moderate quality Further research is likely to have an important impact on our confidence in the QQQŒ estimate of effect and may change the estimate Low quality Further research is very likely to have an important impact on our confidence in QQŒŒ the estimate of effect and is likely to change the estimate Very low quality Any estimate of effect is very uncertain QŒŒŒ Adapted from Guyatt et al.1 Table 2. Differential diagnosis of gastric outlet obstruction Mechanical Motility disorders Benign Peptic ulcer disease Gastroparesis Crohn’s disease Postsurgical gastroparesis NSAID-related stricture Medication-associated dysmotility Anastomotic stricture Systemic disease-associated (eg, scleroderma, amyloidosis) Postradiation stricture Intestinal pseudo-obstruction Foreign body or bezoar Paraneoplastic syndrome Gallstone (Bouveret syndrome) Benign polyps (eg, antral polyps, inflammatory, hyperplastic, inflammatory pseudotumor, hamartoma, Peutz-Jeghers syndrome) Eosinophilic gastroenteritis Extrinsic compression (eg, annular pancreas, chronic pancreatitis with/without pseudocyst) Malignant Gastroduodenal cancer, gastric lymphoma (eg, MALT lymphoma), pancreatic cancer, cystic neoplasm of the pancreas, gallbladder and bile duct cancer, carcinoid, retroperitoneal lymphadenopathy (eg, metastatic tumor, lymphoma), retroperitoneal sarcoma, leiomyosarcoma, GI stromal tumor Children Hypertrophic pyloric stenosis, duodenal or pyloric atresia, antral and duodenal webs, gastroduodenal duplication, gastroduodenal intussusception and gastric volvulus, heterotopic pancreatic tissue in the gastric antrum, diaphragmatic herniation, malrotation and peritoneal fibrous bands, congenital anomalies of the pancreatobiliary system, foreign body, peptic ulcer disease, eosinophilic GI disease, chronic granulomatous disease, Crohn’s disease, lymphoproliferative disease MALT, Mucosa-associated lymphoid tissue; NSAID, nonsteroidal anti-inflammatory drug. EVALUATION before endoscopy. CT is the preferred radiologic test for suspected intestinal obstruction.12-14 Because oral barium Most patients with signs or symptoms of gastroduode- contrast may interfere with subsequent endoscopy, its use nal obstruction or dysmotility will require structural eval- should be minimized or avoided if endoscopy is antici- uation with EGD and/or radiographic studies. If complete pated. Furthermore, high osmolar water-soluble contrast intestinal obstruction or perforation is suspected, initial agents can cause severe bronchial irritation and pulmo- evaluation with radiographic studies should be performed nary edema when inadvertently aspirated in the setting of 14 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011 www.giejournal.org The role of endoscopy in gastroduodenal obstruction and gastroparesis obstruction and thus should be used with extreme cau- trostomy with or without feeding tube placement. Surgery tion.15 Endoscopic examination after gastric decompres- is the preferred strategy for those patients who are poten- sion can usually identify the nature and the precise level of tial candidates for curative resection. Diagnostic laparos- obstruction, but the degree of the stenosis often does not copy or exploratory laparotomy may be beneficial to as- correlate with symptoms. Endoscopy also offers the capa- sess the extent of disease with intent to perform surgical bility of tissue sampling and endoscopic therapy, where bypass as deemed necessary. Endoscopic placement of an indicated. SEMS should be considered provided there is no evidence When structural abnormalities have been excluded, GI of obstruction distal to the site of planned stent deploy- motility can be evaluated by using scintigraphy, radio- ment. In patients with multiple sites of obstruction, palli- graphic contrast techniques, breath testing, electrogastrog- ative decompressive gastrostomy can be considered with raphy, or gastroduodenal manometry. A comprehensive jejunal feeding tube placement or total parenteral nutrition technical review of the diagnosis of gastroparesis was (TPN). published in 2004.16 Gastroduodenal manometry can be Endoscopic SEMS placement. SEMS are composed of performed to differentiate intestinal myopathy from en- metal alloys designed to be constrainable on a delivery teric or extrinsic neuropathy, but the availability of this test catheter, yet resume their desired shape once the con- 17-19 is limited and may not influence therapy. A wireless straint is removed. Although
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